DATA SHARING PROJECT

Loss Description and Causation

Much of your input in this section calls for subjective judgment. To provide consistency, rules and methods of analysis have been set up to guide you to the right evaluation. Definition of the severity, Misadventure and Associated Issue categories have been provided at the end of this section as well as a general categorization of the procedures and conditions as found in ICD-9. A two-hour training videocassette tape on ICD-9 coding is available to provide further assistance in finding and selecting codes. If you would like to view this videocassette, contact the PIAA office. After you read the entry instructions, we suggest you read Part Two of the Case Studies to learn how to code this section.

Field No.	Field Name	Entry	Description
31	Severity	Required	Optional for corporate files. Enter the code which best describes the result of the incident from the following Severity Index table. The severity is determined by following the facts surrounding the patient's condition resulting from the alleged incident until the case closes. The severity can change before the case closes if the patient expires, for example, but only as a result of the injuries or condition. A more detailed description of each severity code can be found in section 11.

Code	Severity
1	Emotional injury only
2	Insignificant injury
3	Minor temporary injury
4	Major temporary injury
5	Minor permanent injury
6	Significant permanent injury
7	Major permanent injury
8	Quadriplegic, brain damages, lifelong care
9	Death
Table 7-A

Field No.	Field Name	Entry	Description
32	Actual Condition	Required	Optional for corporate files. Using the codes from the International Classification Disease, Ninth Edition (ICD-9), enter the actual condition (NOT a misdiagnosis or outcome) from which the patient suffered. If there is more than one, select the condition that is most applicable to the generation of the claim. If a code cannot be found in the ICD-9 manual, please see the section containing the PIAA generated codes in Section 12. Only use "E" codes (from ICD-9 manual) that indicate a primary condition, specifically accidental poisoning (E850 -E869.9) or insect and animal bites and stings (E905 - E906.9). Use 1000.00 to indicate that there was no patient condition relevant to the filing of the claim.

33	Misdiagnosis	Optional	Enter the incorrect diagnosis from the ICD-9 manual. When coding the misdiagnosis, enter the actual condition in the condition field, and indicate the erroneous diagnosis made by the insured in this field. NOTE - This field is ONLY used if the medical misadventure is "error in diagnosis: ("01") and the physician actually identified the disease incorrectly. It is NOT used for failure to diagnosis. For failure to diagnosis, reflect actual condition in condition field only, as no incorrect diagnosis was made.

34	Care Rendered	Required	Optional for corporate files. Enter the ICD-9 code for treatment rendered by the insured to the patient. If more than one procedure was used, enter the one most significant to the claim's generation. If two or more insured physicians are named, code each one separately and enter the procedure each performed. The codes are likely to be different. If a code cannot be found in the ICD-9 manual, please see the PIAA generated codes in Section 12 of this manual.

35	Procedure- Anesthesia	Optional	Enter ICD-9 code for the procedure for which anesthesia was administered. EDIT - This field is REQUIRED if "care rendered" is in the 200's, regardless of whether or not the insured is an anesthesiologist. NOTE - Remember to code the actual anesthesia procedure in the care rendered field. Use this field to give the reason why anesthesia was necessary. For example, if general anesthesia was given for a cesarean section, the care rendered would be the general anesthesia, and this field would reflect the c-section surgery.

36	Misadventure	Required	Enter for code from the following Misadventure Table for the error involved which was the MOST CAUSALLY RELATED TO THE RESULT. If you have many errors involved, you may want to review the determination of error elimination process as described in Section 11. You should enter a misadventure even if the error is only an allegation. If a claim has no medical misadventure, but has legal merit, there should be an appropriate associated issue. To indicate frivolous cases, enter a "99" for misadventure and a "99" for associated issue 1. EDIT - The insured must be an anesthesiologist or paraprofessional if misadventure is in the 50's.

Code	Misadventure
01	Diagnosis error
02	Wrong patient or body part
03	Medication errors
04	Improper performance
05	Failure to instruct or communicate with patient
06	Performed when not indicated or contraindicated
07	Delay in performance
08	Not performed
09	Surgical foreign body left in patient after procedure
10	Patient positioning problem
11	Failure to supervise or monitor case
12	Failure to recognize a complication of treatment
13	Not or improperly performing resuscitation
14	Failure/delay in admission to hospital
15	Failure/delay in referral or consultation
16	Improper supervision of resident or other staff personnel
17	Failure to properly respond
18	Surgical/procedural clearance contraindicated
99	No medical misadventure
Table 7-B

Code	Anesthesiology Misadventure
50	Intubation problem
51	Errors in agent use or selection
52	Problems with patient monitoring in surgery
53	Problems with patient monitoring in recovery
54	Failure to delay a case when indicated
55	Lack or improper performance of preoperative evaluation
56	Problems with administration of blood of fluids
57	Improper supervision of others
58	Tooth injury cases
99	No medical misadventure
Table 7-C

Field No.	Field Name	Entry	Description
37	Treatment Delayed/Not Performed	Required	Required if misadventure is coded "07" or "08" and blank otherwise. Enter the ICD-9 code for the procedure associated with the misadventure. Use ONLY if there was a delay of the procedure or it was not performed. The code in the misadventure field must be "07" Delay in Performance or "08" Procedure not Performed. If there was a delay in performance, this field can be the same as the Care Rendered field. For example, if the physician delayed the performance of a c-section, that code would appear in both the care rendered fields and this field if the procedure resulted in the generation of the claim.

38, 39	Iatrogenic Injury 1,2	Optional	Enter the ICD-9 code for the injury DIRECTLY caused by the acts of the physician. This does NOT mean general resulting injuries but only injuries directly attributable to the physician in the performance of the procedure. For example, "perforation of uterus" or "injury to cranial nerve" is appropriate. Resulting conditions such as "alopecia" or "coma" are NOT. Enter codes found ONLY in Section 12. NOTE - The iatrogenic injury filed should be filled in order of importance.

40	Outcome	Required	Enter the ICD-9 condition code for the most significant/severe injury to the patient that led to the filing of the claim. Outcomes are usually, but not always, different from the condition. For example, a patient presents to the doctor with a fracture of the femur that is incorrectly set by the surgeon and results in a nonunion. The condition would be the femur fracture and the outcome is the nonunion. A listing of commonly used outcomes can be found in Section 12. The outcome code cannot be an ICD-9 procedure code.

41, 42, 43	Associated Issue 1,2,3	Optional	Associated Issue 1 is REQUIRED if misadventure is "99" (no medical misadventure), the other two are optional. Enter code any associated issues that have an impact on the claim from the following Associated Issue tables. These would be other errors that are not medical misadventures and are sometimes legal in nature (e.g. altered record, breach of contract). Other issues including laboratory, x-ray errors and product liability involvement are also indicated in these fields. Definitions are found in Section 11. NOTE - The three associated issue fields should be filled in order of importance. For example, if a claim has two appropriate associated issues, such as vicarious liability and a consent issue, determine which of the two issues is of greater significance and place it in the first associated issue filed.

Code	Associated Issue - Legal
01	Abandonment
03	False imprisonment
04	Breach of confidentiality
06	Failure to confirm with regulation, statute or rule
13	Consent issues, breach of contract or warranty
16	Assault and battery
17	Res ipsa loquitur - self evident
22	Problem with records
23	Billing and collection
24	Communication between providers
26	Vicarious liability
28	Punitive damages
30	Improper conduct by physician
31	Physician with communicable disease
33	Manages care referral problem
35	Religious issues
37	Improper sexual conduct by physician
Table 7-D

Code	Associated Issue - Other
02	Premature discharge from institution
05	Unnecessary treatment
07	Complementary or alternative medications
08	Lack of adequate facilities or equipment
09	Laboratory error
10	Pharmacy error
11	X-ray error
12	Problem with patient's history, exam or work-up
19	Equipment malfunction, product liability, or utilization problem
20	Aseptic technique
32	Third party claimant
34	Surgical/medical device
36	Telemedicine
38	Comorbid Condition (i.e. obesity, diabetes, hypertension)
98	Year 2000
99	Other
00	None
Table 7-E

Field No.	Field Name	Entry	Description
44, 45, 46	Associated Personnel 1,2,3	Optional	Enter codes from the following Associated Personnel table that indicates other persons who had involvement with the claim (e.g. nurse or ER physician). NOTE - The three associated personnel fields should be filled in order of importance to the generation of the claim.

Code	Associated Personnel	Code	Associated Personnel
01	Resident or Intern	14	Nurse practitioner
02	Consultant	15	Pharmacist
03	Radiologist	16	Technician
04	Anesthesiologist	17	Physician's assistant
05	Pathologist	18	Physical therapist
06	Emergency medicine physician	19	Other therapist
07	Other physician/surgeon	20	Patient
08	Dentist	21	Other hospital personnel
09	Podiatrist	22	Family members
10	Chiropractor	23	Other office personnel
11	Nurse	24	Hospitalist
12	Nurse anesthetist	99	Other person or personnel
13	Nurse midwife
Table 7-F